Evidence Update: Joint Pain and Aromatase Inhibitors
Joint Pain and Aromatase Inhibitors Aromatase inhibitors (AIs) have now been established as successful adjuvant therapy for breast cancer survivors who are post-menopausal and whose cancer is estrogen-receptor-positive. These include anastrozole (Arimidex), letrozole (Femara) and exemastane (Aromasin). Unfortunately, nearly half of women taking AIs report joint pain, or arthralgia. It is estimated that 20-30% of patients discontinue AI treatment due to joint pain. The pain and/or stiffness is usually symmetrical (i.e., on both sides) and often affects hands, feet, knees, hip and back. In a recent publication, researchers searched for and evaluated studies that examined the effect of several different ways of managing arthralgia related to AIs. Five types of interventions were identified that have been studied: pharmacological (drug) approaches, acupuncture, nutritional supplementation, relaxation techniques and physical exercise. Pharmacological approaches, including duloxetine (Cymbalta), immunotherapy and changing between AI options showed promise in relieving arthralgia symptoms. Acupuncture was promising in reducing pain in four studies. Two studies showed a possible positive impact of Yoga and Tai Chi on AI joint pain, function and quality of life. Several studies looked at exercise, primarily walking, and found a trend to decreasing pain with exercise, but this decrease was not statistically significant. Bottom Line: There may be several approaches to managing AI-related joint pain. Your medical oncologist will be helpful in choosing what is right for you. Acupuncture, yoga and tai chi appear to be helpful. Exercise, such as walking, shows promise in helping manage AI pain, but further study is needed. Keep in mind, that there are many other benefits of regular exercise for breast cancer patients (see this month’s nutrition section!). Consider joining us for this month’s education event ‘Bones, Joints and Breast Cancer’ and don’t forget that TurningPoint has a weekly Yoga class! Yang GS, et al. Interventions for the Treatment of Aromatase Inhibitor-Associated Arthralgia in Breast Cancer Survivors: A Systematic Review and Meta-analysis. Cancer Nurs. June 21, 2016. [Epub ahead of print]
Evidence Update: Pilates Based Exercise Beneficial
Pilates-Based Exercise Improves Upper Extremity Problems in Breast Cancer Patients It is well documented in the medical literature that breast cancer treatment, particularly surgery and radiation, contribute to upper extremity impairments, including decreased motion, weakness and difficulty doing usual functional tasks. A recent study examined the effectiveness of Pilates-based exercises, compared to combined exercise and home exercise as part of the rehabilitation of shoulder and arm issues for patients going through breast cancer treatment. Fifty-five patients were randomly allocated to one of the three groups: Pilates-based, combined exercise class and home program. The study was 8 weeks long and the Pilates-based and combined groups met three days per week for 40-45 minutes. The combined exercise class consisted of strengthening, stretching and range of motion exercises with a physical therapist. The home exercise group was instructed to do these same exercises at home. Pain, range of motion, strength and function were evaluated before and after the 8 week intervention. There were significant improvements in almost all parameters in both the Pilates-based and Combined Exercise group, and more significant improvements than in the home exercise group. This study showed that Pilates-based exercise results in significant improvement in upper extremity issues. There are, of course, many other benefits of Pilates-based exercise for breast cancer patients including Core strength and Balance. TurningPoint offers weekly Pilates classes with a Physical Therapist who is both an expert in breast cancer rehabilitation and a certified Pilates instructor. Pilates may be a great adjunct to your rehabilitation plan to help you get back to the things you love to do! Alpozgen AZ et al. Effectiveness of Pilates-based exercises on upper extremity disorders related with breast cancer treatment. Eur J Cancer Care (Engl). 2016 Jun 23. doi: 10.1111/ecc.12532. [Epub ahead of print]
Evidence Update: TurningPoint – Avon Breast Center at Grady Study Published
Hot off the press! This month’s evidence update features a study published this week by TurningPoint and our research partners at The Avon Breast Center at Grady Hospital and Emory University. The study examined the benefit of early identification and treatment of the physical side effects of breast cancer treatment, such as pain, limitation in motion and function and lymphedema (chronic arm swelling). Participants were 120 patients being treated for breast cancer at the Avon Breast Center at Grady Hospital. Grady is a safety net hospital in downtown Atlanta. Study participants were primarily underserved and minority women who would not typically be able to access this type of care. Pain, range of motion, arm volume and function were evaluated by a physical therapist at designated intervals. These assessment intervals were: pre-op, early post-op (2-4 weeks), 6 weeks and 3, 6, 9 and 12 months after surgery. All patients received range of motion exercise and education. Patients with identified impairments such as significantly limited range of motion, axillary cording or lymphedema received more intense individualized rehabilitation. One third (36) of the patients required this more intense intervention. Sixteen patients developed lymphedema during the first post-operative year. In 12 patients, lymphedema was identified and treated early and managed at low levels (<10% greater than baseline measure). In just four patients, lymphedema progressed to more severe levels, defined in the study as 11% greater than baseline. Of interest is that participants who needed more intense rehab intervention had significantly lower arm function and more pain in the early post-operative phase as well as more nodes removed and higher stage of breast cancer. This finding may help us to identify early which patients will require more intense rehabilitation and plan their care accordingly. Our research team concluded that health care providers should have heightened awareness for rehabilitation intervention and that early identification and management of lymphedema, range of motion and functional issues appear to benefit breast cancer patients. The work exemplifies TurningPoint’s commitment to evidence-based practice and reducing barriers to breast cancer rehabilitation and exercise. Read the published study here. Lai L, Binkley J, Jones V, Kirkpatrick S, Furbish C, Stratford P, Thompson W, Sidhu A, Farley C, Okoli J, Beech D and Gabram S. Implementing the Prospective Surveillance Model (PSM) of Rehabilitation for Breast Cancer Patients with 1-Year Postoperative Follow-up, a Prospective Observational Study. Ann Surg Oncol. 2016 Jun 22. [Epub ahead of print]
Evidence Update: Lymphedema At Risk Activities: Fact or Fiction?
Many of the precautionary guidelines related to lymphedema provided to breast cancer patients are anecdotal and not based on research. Unfortunately, many of these guidelines place a large burden on patients and clinicians who go to great lengths to abide by them. The avoidance behaviors can often be more impactful on quality of life than actually having lymphedema! A recent study, published in March 2016, was the first large scale, prospective study to investigate whether there is an association between certain activities and increases in arm volume in patients treated for breast cancer and screened for lymphedema. These activities include blood draws, injections, blood pressure readings, trauma, cellulitis (infection) in the affected arm and air travel. Subjects were 632 patients (760 at-risk arms) with newly diagnosed breast cancer. Bilateral arm volume measurements were performed preoperatively and postoperatively at 3 to 7 month intervals using a perometer. At each measurement, patients reported the number of blood draws, injections, blood pressure measurements, trauma to the at-risk arm(s), and number of air travel flights taken since their last measurement. Arm volume was quantified using the relative volume change and weight-adjusted change formulas. In the total of 3,041 measurements carried out on the 632 subjects, there was no significant association between change in arm volume and undergoing one or more blood draws, injections, number of flights, or duration of flights. As has been previously found in other studies, factors significantly associated with increases in arm volume included weight gain (body mass index), axillary lymph node dissection and regional lymph node radiation and infection/cellulitis. This study suggests that although cellulitis increases risk of lymphedema, blood draws, injections and blood pressure readings on the affected side, as well as air travel, may not be associated with arm volume increases. The results of this study will provide clinicians and patients with much better evidence regarding risk factors and triggers of lymphedema. The clear risk factors for lymphedema are the number of lymph nodes removed, radiation to regional lymph nodes and higher BMI. Infection, or cellulitis, of the arm may be a trigger for lymphedema. Simple infection precautions make sense, such as using gloves when gardening and topical antibiotics for small cuts on the affected arm, https://suriaplasticsurgery.com/valtrex-valacyclovir/. Patients may prefer to continue to have blood draws and blood pressure taken on the unaffected arm, but should understand that these do not appear to trigger lymphedema based on this study. The issue of I.V.s was not addressed in this study and patients may want to continue to avoid these in the affected arm since, unlike a blood draw, fluid is being added to the limb. Flying does not appear to be a trigger to lymphedema; however, for women at moderate to high risk, TurningPoint physical therapists advise patients to travel with compression garments, in case swelling or lymphedema should become apparent while out of town. Ferguson CM et al. Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer. J Clin Oncol. 34;7: 691-698.
